Miller, Nathaniel E.

Introduction Correct inhaler technique is of utmost importance in the optimal delivery of therapeutics utilized for respiratory illnesses. Previous research suggests that the ability of both patients and providers to correctly use these inhalers is sub-optimal and is associated with poorer patient outcomes. Further education about inhaler types and technique as part of residency education could serve to correct these trends. Methods Family medicine residents were taught correct inhaler technique with an inhaler training device (In-Check TM DIAL G16) using a didactic lecture with hands-on teaching exercise utilizing pharmacy interprofessional teaching. We assessed pre- and post-intervention comfort and knowledge of correct inhaler technique. Results Twenty of twenty-seven eligible family medicine residents attended an interdisciplinary workshop with clinical pharmacists with the purpose of improving inhaler technique comfort level and knowledge. A pre- and post-knowledge test and comfort questionnaire were provided to those participating. Comfort levels with prescribing different inhaler types increased after the intervention and knowledge of different inhalers improved. Conclusion Use of an inhaler training device coupled with an interdisciplinary lecture format improved provider knowledge of correct inhaler technique and comfort with prescribing inhalers.

Introduction: Online self-triage is a newer eHealth modality, and there is a paucity of research on patient adherence to self-triage recommendations. We evaluated patient compliance with online self-triage guidance to seek emergency care and compared to nurse-triage adherence rates. Methods: We reviewed primary care empaneled patients who had either nurse phone triage or an online self-triage encounter that resulted in an emergency care recommendation between January 1, 2023, and November 30, 2024. Patients triaged for mood concerns, abdominal pain, chest pain, constipation, cough, and diarrhea were included. We reviewed whether patients had an emergency department visit within 24 h of their triage encounter. For self-triage encounters, we also examined whether patients called nurse triage within 24 h of their self-triage encounter. Results: There were 689 self-triage and 2,385 nurse triage encounters with an emergency care endpoint. Adherence to the emergency care recommendation was substantially lower after self-triage (22%) than after nurse triage (61%). Patients who underwent nurse triage were significantly more likely to seek emergency care than those who self-triaged (odds ratio of 5.4 [95% CI: 4.5–6.6] p < 0.001). Both male and female patients were less likely to follow emergency care recommendations after self-triage compared to nurse triage ( p < 0.001). There were 258 patients with an emergency care endpoint from self-triage who chose to call nurse triage (median time between encounters of 16 min). Only 78 (30.2%) also received an endpoint recommendation for emergency care, and 73% of those patients sought emergency care within 24 h. Discussion: Patient compliance with online self-triage recommendations to seek emergency care was poor and significantly less than nurse triage. Follow-up calls to nurse triage led to higher compliance. Health systems using online symptom checkers should consider employing mechanisms to follow up on emergency care recommendations. Further research should elucidate factors that contribute to patients’ willingness to follow care recommendations.

Prostate-specific antigen (PSA) screening has played a critical role in reducing prostate cancer mortality but remains controversial due to concerns regarding overdiagnosis, overtreatment, and inconsistent screening guidelines. In 2012, the United States Preventive Services Task Force (USPSTF) issued a grade D recommendation against PSA screening, leading to a national decline in PSA testing and prostate biopsy rates. This was followed by an increase in the incidence of metastatic prostate cancer at diagnosis. The USPSTF has since revised its recommendation to grade C, emphasizing shared decision-making for men aged 55 to 69 years. However, variability in screening recommendations across professional societies has resulted in clinical uncertainty, particularly for primary care physicians (PCPs), who frequently initiate PSA testing and urology referrals. This review provides an evidence-based overview of PSA screening tailored for the PCP. We performed a comprehensive literature review using Ovid MEDLINE, PubMed, Embase, and the Cochrane Library, including systematic reviews published between January 2020 and April 2025, and current guidelines from the American Urological Association (AUA), National Comprehensive Cancer Network (NCCN), European Association of Urology (EAU), and American Cancer Society (ACS). We summarize the evolving landscape of PSA screening and its integration with contemporary tools such as shared decision-making, multiparametric magnetic resonance imaging (mpMRI), and transperineally targeted biopsy. We advocate for initiating PSA screening between the ages of 45 and 49 in men with average or elevated risk, based on long-term evidence demonstrating the value of an early baseline PSA level and risk-stratified follow-up. This approach, coupled with improved diagnostic tools, can help PCPs navigate guideline variability and implement a rational, common-sense strategy to maximize early detection while minimizing harm.

Background: Patients performing self-triage for chest pain need to pick an algorithm which includes questions pertinent to chest pain to triage accurately. Objective: Our study reviews patient self-triage choices and outcomes for patients who completed an online self-triage encounter before being triaged by a nurse for chest pain. Methods: Patients who underwent telephone nurse triage for chest pain, and also had an online self-triage encounter within the prior 24 hours were reviewed for the frequency with which they chose “chest pain” as their symptom to triage for during self-triage, whether they reported chest pain during the self-triage encounter (if asked as part of the algorithm for their chosen self-triage symptom) and whether the patient had any follow up evaluation within 1 week. Results: There were 70 self-triage and nurse triage dyads during the study period where triage nurses chose “chest pain” as the primary symptom to be triaged for during the telephone triage encounter. Of these, only 5 (7.1%) patients chose the “chest pain” self-triage option during online self-triage. During the self-triage encounter, 50 (71%) reported chest pain, 10 (14%) denied chest pain and 10 chose to self-triage their symptoms with an algorithm that did not include a question on whether chest pain was present. Of the 70 total dyads 59 (84%) had a follow up emergency department (40 patients) or office visit (19 patients) documented. Conclusion: Most patients chosen to be triaged for chest pain by triage nurses did not choose the online self-triage algorithm for chest pain even though the majority did report chest pain during their self-triage encounter (when asked). This is concerning from a safety perspective as a non-chest pain self-triage option chosen by the patient may not always ask about the presence or absence of chest pain and thus could increase the risk of being triaged inaccurately. Implications for improvement of self-triage could include diagrams for patients to choose the symptom area.

A 33-year-old female presented with finger pain, swelling, and erythema was diagnosed with cellulitis and treated with antibiotics. Persistent symptoms led to further evaluation including a point-of-care ultrasound revealing a cystic structure, concerning for abscess. Incision and drainage yielded a solid mass rather than fluid. Pathological examination revealed a schwannoma, a benign peripheral nerve sheath tumor. This case highlights the rare presentation of a schwannoma mimicking an infectious process and emphasizes the importance of considering peripheral nerve tumors in the differential diagnosis of soft tissue masses, especially when the clinical course is atypical. It also underscores the value of pathological examination in establishing a definitive diagnosis and preventing misdiagnosis, which can have implications for patient management.

Objectives Guidelines advise repeat screening within four months if Papanicolaou (Pap) results are unsatisfactory for evaluation. This utilizes healthcare system resources and may decrease patient satisfaction due to needing a second clinic appointment. We assessed unsatisfactory Pap test (UPT) rates and associations with clinician and patient characteristics to inform future interventions to decrease UPTs. Setting Multisite midwestern United States primary care practice. Methods Retrospective analysis of women aged 21–65 with a Pap between 7/1/2021 and 6/30/2023. Bivariate and multivariable logistic regression analyses were conducted to assess for associations between UPTs and clinician gender, degree, residency status, and experience. Results Of 51,195 Paps completed, 2.3% were unsatisfactory. Female clinicians performed the most Pap tests (83.2%) with slightly less likelihood of UPTs compared with male clinicians ( p = 0.015). There was no significant difference comparing physicians to advanced practice providers in UPTs ( p = 0.18). Residency training level did not affect UPT rates ( p = 0.95). Clinician experience was associated with higher UPT rates in first and fourth quartiles (least and most Paps performed) compared to middle two quartiles ( p = 0.004). UPTs were more likely among women aged > 50 years old ( p < 0.001), married ( p < 0.001), and Asian ( p < 0.001). Conclusions Clinician characteristics played a small role in predicting UPTs but patient age may be the factor most amenable to intervention to lower UPTs. Transitioning to primary human papillomavirus (HPV) screening in peri/post-menopausal women could decrease UPTs given Paps are performed on the clinician-collected cervical specimen only if HPV testing is positive.

Introduction: Online self-triage/symptom checkers are a relatively new e-Health modality. We aimed to evaluate the degree to which patient’s chosen symptom during the use of an online self-triage tool was congruent with that chosen by a nurse performing phone triage. Methods: Patient encounters from September 1, 2022, to September 30, 2023, were reviewed for patients who completed both online self-triage and a subsequent nursing phone triage within 24 hours. The symptoms chosen by the patient for their self-triage encounter and the symptoms chosen by the nurse during the subsequent nurse triage were reviewed. The symptoms chosen in these two triage encounters were then compared for congruency. A subset of our database was evaluated for congruency between the self-triage and the nurse phone triage endpoint recommendations. Results: There were 5,443 encounters meeting inclusion criteria to study for congruency between self-triage and nurse triage symptom choice. The range of time between self-triage and nurse triage ranged from 0 min to 1,439 min (23.9 hours) with a median of 23 minutes between self and nurse triage encounters. Symptom congruency between the two methods found 74.2% (4,038) to be completely congruent while 989 (18.2%) were somewhat congruent. Only 7.6% (416) had no apparent congruency. Out of 1,705 self and nurse triage dyads eligible for study for agreement between endpoint recommendations, 244 (14.3%) were under-triaged, 1,110 (65.1%) were triaged to the same level of care and 351 (20.6%) were over-triaged. Conclusion: Congruency between symptoms chosen by the patient for triage and nurse triage were highly congruent with only 7.6% of the sample showing no apparent congruency between the self-triage symptom and the nurse triage symptom. When compared to nurse triage, most self-triage endpoint recommendations were either triaged to the same level of care or were over-triaged to a higher level of care.

Introduction: Online self-scheduling of medical appointments is increasingly common. An automated waitlist can be used for patients who desire an earlier appointment time if one becomes available after they are scheduled. Our study examines outcomes of an automated waitlist and self-rescheduling process. Methods: We studied outcomes of an automated waitlist self-rescheduling process in which patients with existing appointments elected to be placed on an automated waitlist for an earlier appointment offer. When software found earlier dates for the same visit type, patients were then notified through an automated process and could self-reschedule. We reviewed appointments for which patients were sent new offers when earlier appointment slots were found. We compared the accepted appointment offers with the original scheduled appointments and determined the number of days that the appointment had been moved up. Results: Spanning the calendar year 2023 there were 1 019 698 appointment offers generated by an automated waitlist process for 229 998 appointments and sent to 164 248 patients. The waitlist process automatically found open appointments as they became available and sent the first new appointment offer within 2 days after being placed on the waitlist for 74 736 (32.5%) of the 229 998 waitlisted appointments. Patients sent back at least 1 response for 104 554 (45.4%) of the waitlisted appointments. Of the responses, 56 636 accepted one of the sent offers for an accept rate of 24.6% (56 636/229 998). For accepted, moved-up visits, appointments were self-rescheduled earlier by a mean of 22.6 days (95%CI; 22.2, 22.9, P < .0001). Conclusion: New appointments can be successfully self-rescheduled using an automated waitlist process that allows patients to accept or decline new appointment offers. This process can increase the efficiency of scheduling and decrease appointment wait time for patients desiring more timely access to healthcare. In addition, this process can be successfully applied across several different appointment type categories.